Medicare Compliance & Reimbursement

If you were wondering whether the Centers for Medicare & Medicaid Services (CMS) would be reviewing office/ outpatient E/M service claims as practices transition from the old to new guidelines, the answer is yes. However, in a new fact sheet CMS does offer a tip on what reviewers will be looking for when time is used to determine the visit level.

Details: On Jan. 11, CMS released a short fact sheet on the 2021 E/M guidelines finalized in the calendar year (CY) 2021 Medicare Physician Fee Schedule (MPFS) final rule. The brief review looks at the “the new coding, prefatory language, and interpretive guidance framework” for office/ outpatient E/M service codes (99202-99215) issued by the American Medical Association’s (AMA’s) CPT^® Editorial Panel and how the changes impact Medicare providers, the fact sheet shows.

The agency also references claims reviews while giving practitioners a little documentation advice.

“Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit,” CMS says in the fact sheet.

Reminder: Beginning on Jan. 1, practices started basing code selection for 99202-99215 on medical decision making (MDM) or the total time the physician spent on the patient encounter on that date of service. Under the CY 2021 MPFS, CMS finalized that history and exam would no longer be used as the key components to level 99202-99215.

Providers should now be leveling codes 99202-99215 based upon either MDM or time — not both.

Resource: Review the fact sheet at https://www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf.